Healthcare Provider Details

I. General information

NPI: 1114044435
Provider Name (Legal Business Name): RETINA & VITREOUS CONSULTANTS OF WI, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N MAYFAIR RD SUITE 901
MILWAUKEE WI
53226-1309
US

IV. Provider business mailing address

2600 N MAYFAIR RD SUITE 901
MILWAUKEE WI
53226-1309
US

V. Phone/Fax

Practice location:
  • Phone: 414-774-3484
  • Fax: 414-778-3445
Mailing address:
  • Phone: 414-774-3484
  • Fax: 414-778-3445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SHARATH C RAJA
Title or Position: PRESIDENT
Credential: MD
Phone: 414-774-3484